ER Intern: Peds ER

ah.... finally back in the ER. Its like I forget everytime I'm away how awesome the ER is.  The pediatric ER is a bit different than the adult ER. Most kids who come in are assumed well until proven otherwise-- the exact opposite mentality of the adult ER.  This is because the reality of kids is MOST of the TIME if it looks bad, its not. That said there are plenty of really sick kids out there- so don't use that as explicit medical advice. Most of why kids come into the ER are in 3 categories: 1) they shouldn't be there (cough, flu, runny nose, etc)  2) traumatic some kind of accident (broken leg, swallowed a quarter, abuse, etc) 3) congenital/genetic problems - these can be catastrophic and/or change the bodies abilities at a cellular level. This last category is every doctors nightmare (or at least mine) because all the rules are changed, what would make a normal person better can often make them worse or even kill them inadvertantly. 

That said, 90% of the patients belong to category one which means we see maybe 3 times the patients as compared to the adult ER. That means twice as many stories and way way busier. I spent many a shift so busy I could not pee for the full 12 hours.  Anyhow down to the stories and the pictures, all of which were taken with parents and patients permission.

This kid has a machine sewing needle through a finger. I took it out no worries. :) 

The tongue below is a classic exam question and often not seen so textbook-perfect. It is what is known as "strawberry tongue" and when accompanied with a rash, fever, sometimes sore throat is also apart of scarlet fever. Scarlet fever isn't as scary as it was before antibiotics- it can be treated.  It doesn't cause as many heart infections now. 

 Another story is one that caused quite a mystery in the department. A girl who came in with purple skin from her bra line to her panty line. Although I didn't think to take a picture of it until it started fading you can see the distinction if you look... It was crazy. It was so distinct and we couldn't figure it out. It was obviously venous pooling but we couldnt' figure out why. 

Last but not least. A diabetic type 1 (juvenille) and its a very distinct foot infection of the skin also known as cellulitis. This girl wanted to go back to school, she had been in the hospital and ended up having to skip a grade. Since she didn't want to have that happen again, she has been walking around on these until they started turning purple (look at her ankles)....  What can I say some kids really like school... way more than I ever did.

ER Intern:Radiology/EKG

This rotation is the most easy of all.... we often call it 'radioholiday'. Not much else to say.

ER Intern: Eye Opening Moment

So working on Ortho nights has really opened my eyes. It kinda shocks me. It shouldn't but it does. I've always heard those horror stories about the ER docs. The ones where they call consults without having seen the patient or ignore them to let the consulting docs take care of them. I always knew that maybe those things happened in the "bad ERs" or when that one really dumb ER resident who was so lazy was on.

But being on this rotation showed me that that side does exist and it happens in my home ER. And it happens often. Consults that get made before resident has even looked at the patients. I saw it.

I saw a patient who had a broken leg, but the resident had not yet seen her. She had fallen weeks ago. She was scared and dirty, unbathed. She said her husband wouldn't let her come to ER, she had been dragging her leg around for weeks. She said after awhile it didn't hurt anymore. And we asked how she broke her leg, she thinks it broke before she fell.  Her xrays show weak bones, necrotic and dying. And after hearing she had leg pain and seeing the xray, no doctors and no nurses went in the see the patient. She was waiting for HOURS before anyone saw her. And it needed way more than just an ortho consult. And the resident he was one of my upper levels, someone I had once respected-- he in no way apologized or admit he made a mistake instead he acted like it was a normal occurance. And indeed it was not all that uncommon. THis is just one of many stories like this that I have.

Situations like this make me understand how the consultants can not take us seriously.  And also made me seriously question the quality of my program.  I hate that feeling.

ER Intern: OB

Across the country, the ER OB rotation is notorious for being bad. Perhaps its because the personality of the OB and the ER is so different, or perhaps because all the waiting makes the OB residents more protective of (or impatient for) their deliveries. All I know is almost all ER residents complain about it or view it as a "vacation month".

For me, after getting off a joke month there was no way I was just going to sit around on this rotation. I made up my mind to be pushy and butt into the deliveries until I met my designated 10 deliveries required for graduation of ER residency. But when I showed up the first day and saw there were 10 students (mix of M3, M4, and auditioners) plus a family med resident and an anesthesia resident I knew the odds were stacked against me.  I did what I could to play those odds, volunteering for nights only and on top of that only nights over the weekends to clear my way.  But it was still hella difficult with even the ob residents resisting my help. I was banished to the "OB ER" (note this is not a true ER, just our nickname) where I drowned in vaginal bleeds usually resulting in dead babies and rule out labors for women who were simply sick of being pregnant. While I surprisingly found this area to be helpful since this is the type of patients I will be seeing in my own ER one day-- I also am required to get 10 deliveries and I was determined.

After lots of smiling about scut work and doing extra notes and other simple tasks to get a few residents trust, I got my first few in rapid-fire sequence. Finally! I caught 3 babies in the same night and felt triumphant!!  Then I got put on the backburner because "you already got some deliveries" and the poor M3s will never get another chance blah blah.

In the end, I only got 8 of my 10 the other two I had to simply watch someone else do.  But those last 5 i really had to sharpen my elbows and butt people aside or steal from students (which i try not to do).

As far as crazy stuff... I had no shortage of good stories despite my struggles for deliveries. And I must say the ones I did catch all seemed to be a story- there weren't really any normal married ladies having normal infants with a supportive husbands. It always seems like there is some drama. Someone cheated or they are too young or too fat or just plain crazy or the baby is not healthy or too young or there is an infection or the mom has a problem and emergent c-section is happening NOW.

For example, one young girl whose boyfriend SNORED in the chair while she was bleeding out. The postpartum hemorrhage was bad but then we looked at the dried off baby and took a picture. Look at that left leg... so white.  Turns out he had a DVT (blood clot) in his leg. Was born that way.... say what??!?!

I got to see a surprise vaginal frank breach (butt comes out first instead of head) the risk of these is very high because they get stuck so often.... so usually they go to csection. But she was just pushing and oops, there is a baby on the bed, came out butt first and nobody was helping it! Good thing everything ended up okay!

I also saw a 3 minute shoulder dystocia (the baby's shoulder was stuck). This is a huge scary complication that still happens alot today. Usually from mom's who are diabetic or babies who are too big for mom's pelvis. This can cause death of baby and death of mom. This one resulted in 3 hands inside mom and an episotomy (cutting mom's vaginal opening all the way down to rectum).  All of these things were terrifying, but incredibly informative. I remember thinking, Wow. This baby might not live through this.  And then I thought, I could be watching this baby die and the mom could be next. Birth is scary.  It terrifies me that so many people take birth control so lightly. Your body is never the same.

And overall, I don't consider my OB month a waste. Learned lots. Now scared to ever have kids myself.... Guess i better pick a guy who I'd trust to raise my kids without me.  Scary.

ER Intern: Anesthesia/Ultrasound

So yeah. I don't really know what to mention here. These rotations are a bit of a joke and everyone knows it. It sucks that this rotation is so close to the beginning for me because i'm ready to learn, I'm ready for my butt to be handed to me and to subsequently become a more bad-ass doctor.

Instead, I sit here and get about 2 intubations a day and go home at noon. Get so bored at home I clean and panic about how I'm not learning anything. hahaha. Panic mode meltdown.

Then 2 weeks later, I just walk around the ER for a few hours everyday ultrasounding random people to try to teach myself how to use the machine. In ER, the ultrasound machine can become a great tool for diagnostic purposes and can help rule out acute, life-threatening problems faster and more efficiently than any other modality. (Gallstones, ectopic pregnancies, elevated intracranial pressures in the eye, AAA, hypovolemia, blood in the belly, and other more mundane uses like abscesses and guiding IV access). However, at our program at least there is nobody to train us. {EDIT: there is officially, but that person is never around and tends to be a sports med person, so unless its a torn muscle, don't ask}.  This frustrates me, as they give me a couple of videos to learn from then let me loose. And I can only train myself to the point where I don't know what I'm looking at or how else to hold the probe to get a better image.  At one point an upper level came to help, but she knew almost as little as I did.

This month generally bodes poorly as it reflects for me that I won't likely know how to use ultrasound effectively when I graduate here. And its been generally a huge emotional downer, because nothing takes you down when you're ready to learn and be challenged like nobody giving a shit. There is nothing else to do but sit back and study for step 3 and hope next month will be better.

For those of you interviewing- look at your possible future program director. Are they the kind of person who will get things done or do they have a lot of "filler" rotations. I really should have asked these kinds of questions... but then again, I dunno if they would have told me about them or not.

ER Intern: what to study

During the day I carry a pad and ppr to keep track of what to read when I go home, a maxwells because it has cm on the back mostly, and also the Tarascon emergency medicine pocketbook. I love having all those facts at my fingertips. I do use Medscape on my phone because its free, but I find I don't have time to use uptodate or other online resources as much as everyone else seems to.  I do have a black pocket sized notebook in my bag i call my little black book... I write down all my workups and fun facts and other things I learn in it, so I can constantly reference it. 

The two big texts in emergency medicine are Rosens and Tintinelli's. While both are texts full of information, I don't really like them all that well. I just don't seem to study well from them and they don't have quick facts. I can't carry them with me and I don't find them all that practical. Plus they are sooo expensive.

I really like the podcasts:  EMbasic, EMCrit, and EMRAP.   The first two are FREE and only 20 mins per episode. The last one is more for ER only people updating old criteria and the like.  But These three have gotten me through many jams and its easy to listen to one on the way to and from work or at the gym.

I also really depend on First Aid for the Emergency Medicine Clerkship or as resident First Aid for the Emergency Medicine Boards.  These have had the basics of things I need to know are are relatively cheap.


Hope this helps.

ER Intern: BushHog vs. Legs

So while everyone in the ER knows that the most dangerous thing you can do with yourself when guns are involved is "mind your own business" because that seems to be the #1 reason how people get shot.... what you didn't know is if you are around.... Mowing your law with an industrial mower, is the worst thing you can do for your feet. This last week we have had 4 catastrophic bushhog accidents.

It appears on the screen as bushhog vs leg catastrophe. There is even a billing code for this because it happens so frequently.  I did happen to get an image of one of the more minor injuries as see here. The coolest part of this particular injury is that I was able to take a video of the posterior tibial pulsating because you don't have to feel for his pulse in this one, you can just watch it! Haha. I was just waiting for orthopedics to come down and ask about his neurovascular status.  This guy was pretty lucky. Wile his skin is gone, his achilles tendon and main artieries are intact. He was also able to walk away from the runaway bushhog with this injury.  The will most likely have to graft some skin to cover this over, but he got away scott-free mostly.

Not everyone was this lucky. One guy was coming in by air, but the paramedics with his wife came about 10 minutes early and handed me a lunch box full of grass and toes still in socks.  When he arrive, he had bilateral (both sides) amputation. It was just ground meat that was oozing blood. He had done something that saved his own life. He'd taken off his belt and put it around one leg, the one with the biggest arterial bleed. Even the surgeons gave him kudos for the ability to recognize he needed to stop the bleeding and having the sense to pull the belt TIGHT enough to actually stop the bleeding.  He saved his own life. :) smart guy.  Well minus the drinking and mowing lawn combination.


Here is a guy I saw 24hours after the ATV vs. parked truck event. He reall messed up his girlfriend who had come in the previous night, but this was how his arm looked. He was just walking around with that open and moving it etc etc.... kinda crazy.   We just sewed that sucker up and let him go on his way...

ER Intern: Rashes....

So here are a few crazy cases that should get mentioned. The first may not sound all that cool, but it was my first diagnosis without the help of anyone. And of all things it was hematology. Who would have guessed??

So 16yo kid comes in and presents with "rash" now you know to be suspicious of easy cases in this ER so I'm going in pretty suspicious already.  As you can see from the pictures this is not just a rash, its petechiae, largish all over his body. Petechiae are small bruises under the skin from burst capillaries. And they are all over his
body.  For some freak flash of awesome, the first question I asked after looking at this is are they in your mouth? And yes, yes they are. Along with his bleeding gums.  And I knew, this is ITP (idiopathic thrombocytopenic purpura).  And yes, low and behold his platelets came back at 3. Yep a big ol' 3. So workup for this is to start high dose steriods and call the hematology doctors at 4am because this is legit. And when I said, platelets of 3 - they came right in. :)

Kinda neat.  Lets see another cool case I got was someone in legit SVT with a HR of 290s, sweaty and diaphoretic not responding to adenosine x 3 doses -- so I got to push the shock button. Popped him right out of it... although the guy levitated off the table and screamed "SHIIT" that rang through the whole ER. hahaha. Good thing I gave him drugs so he won't remember how much that hurt. This is the picture of the monitor! Its real.... all the board questions we've been studying are REAL.....

Hm... Another case that was also kind of a mystery case. A transfer from an outside hospital. A guy who had a syncopal or seizure event and came in with a myriad of questionable physical findings. He also had a petechial rash only on his chest and armpits with a purple tongue that was large and

swollen. He was on lisinopril for about 1 year and many were worried he had angioedema. He also had some swelling of the sublingual tissue under the tongue which was different. He was transferred because they were worried about his airway.  You can see that the purple bruising is only on the lateral aspect of his tongue, which gave me a clue as to the fact he'd probably had a seizure earlier that night. I also brainstormed that the petechial rash was most likely from apnea during his seizure that popped the capillaries in his chest. This is often a first sign of cause of death on cadavers in the morgue. My pathology teacher would be so proud of me! So we admitted him, but I didn't give him any angioedema medications because he bit his tongue so hard its probably swollen with all the blood. BAM! I was proud to have sorted this out.

ER Intern: ER Rotator Month-- Incidental Findings

So something I have been learning a whole lot about that seems to be a troublesome topic for many a new doctors, especially in the ER -- is what to do with indicidental findings.  How far do you go into a workup for something that the patient did not come in complaining about?

There is no awesome straight forward answer because many times patients don't know what is important, especially when they are scared or really sick. Who cares about that cat bite a week ago when the patient has a headache?  WE DO, but the patients don't understand that the bacteria from the cat bite went through their bone and infected not just the bone but their blood stream with is causing them to have a headache and be admitted to the hospital.  It is this simple problem that separates a physician from a medical student or intern. What is really important and to some degree what are the right questions to be asking?  This is the "art" of medicine you keep hearing so much about.

Its also something I keep running into as a new physician that makes me look around helplessly. These are things that very few studies have been published on and very few discussions in medical school or residency discuss. The problem with these is generally they aren't a big deal and can cloud your judgement with what the patient is complaining about now. But there are always exceptions especially when the incidental finding is sorta a big deal.

Milliary TB

So here are a few random cases to give you an idea.  I had a gentleman come in complaining of leg and arm pain with a small amount of dyspnea. He is very concerned about his pain and he knows he has a kind of arthritis. The man is about 50ish and is very lean and tall (some would say Marfaniod). Despite this joint pain problem, the real reason his doctor sent him to the ER is that his HR is 45 as I am looking at the monitor. He does not have a history of this and he is not a great athlete.  The patient could give a rat's ass about his HR, he just knows that he's a bit dizzy because the pain in his joints gets to him and he wants something for this joint pain. You can't get him off the freakin subject.  So I order up a cardiac workup, trying to figure out what to do with guy and completely frustrated that I can't get him off the topic of his joint pain. I even throw in a little 800 Ibuprofen medication when I put in orders to help him out.  Anyhow, the chest xray comes back and is this.... I know its hard to see but you can see many tiny nodules scattered throughout the lungs in both fields. And I check the radiologists read just to seek their opinion, yep.... Milliary TB. Uh.... talk about a hell of an incidental finding! So what do I do with this guy now? Obviously I can't just let him go home. Still have no idea why his heart rate is in the 40s, but he has no chest pain and is complaining of joint pain. Alright well TB can go into joints, so I do a generalized xray of a few of his extremities and all it shows is some degenerative changes from real arthritis.  So after some discussion with attending, we decided to do a CT scan of chest to confirm this TB and also see if maybe the TB spread to the heart which would cause his low HR. Maybe.... Alright so we're fishing but obviously this guy is a crazy mystery case. So CT comes back clean other than milliary TB in the lungs.  So I admit him and hope that the internal med folks can figure out what the hell....

There was another guy who was rather cachetic looking came in presenting of some headache. He was older and really not talking much to us, he was a transfer case and didn't have any paperwork for us. So when I talked a little about his headache it was like pulling teeth to get him to tell me any

information. But then I did an abdominal exam.... Oh wait sir, how long have these nodules been here? "Oh yeah... i forgot to tell you. I have stage IV liver cancer and am still on chemo. But also I am a full code."  Yeah! sorta a big thing to know! This guy was suddenly a chatterbox. He even asked me for a rice crispy treat, which i eventually caved, as you can see from the picture. Talk about a crazy finding tho! We immediately were able to treat his headache and nausea vomiting better because we knew it was from chemo. Although I felt sad leaving the room knowing that with tumors like that, he probably wasn't going to make it too much longer. :(  Its horrible to see those kinda patients.

Another weird case was someone coming in complaining of abdominal pain. The guy obviously is having a reoccurence of his pancreatitits since his lipase is 1476. But for some weird reason he is also anemic and since I'm learning the computer ordering system I decide to try the order set, which is a series of standard orders for one complaint. (for example there is an order set for pneumonia or chest pain, etc).  I order up his anemia workup because well he's obviously gunna be admitted. About oh I dunno 7 hours later the intern for internal medicine calls my phone and wants to come talk to me. She's all excited and wants to "pick my brain" and i'm like sure.... So she wants to know how I knew to order the malaria test on this guy because it came back positive! Say what?! Apparently, all the internal med people are all real impressed with me now, which is ironic since all i did was use the order set for anemia.  I told her I didn't think of it and it wasn't my genius. But moral of the story is... USE ORDER SETS. People will think you're smart.

On another randomly intriguing topic. There was a study recently published that we chatted about in conference the other day. It was on "gestalt" this magical ability of a doctor to have a gut feeling about if a pt is sick or really what their diagnosis is. Its what makes doctors keep ordering tests when all the usual tests are negative.  I guess a study actually looked at the accuracy of gestalt in the ER about PEs.  And Interns have a gestalt accuracy of pt having a PE about 71% and Attendings have about 78% accuracy.  I find this interesting and also weird that somebody actually studied this....
now I must acquire another 7% gestalt.... which scares me because it must be one heck of a big 7%.

ER Residency: ER "rotator" month

So I'm starting out in the ER. Its a little bit of pressure because I want to be good at everything, and I'm obviously not. That said its only a "rotator" month. So here, they halve the ER and it has 1 upper level and 1 lower level ER intern in each section. The residents who are NOT ER (from psych, internal medicine, OB GYN, etc) are added to one of the halves but are expected to do less. By that I mean carry fewer patients, go slower, and generally ask more questions. They also get reduced hours (they don't work the full 12 hour shifts) and they also only have 16 shifts a month instead of our usual 18.

So as ER interns our first month in the ER (mine just happens to be the first month) we are "rotators" so we can get used to the flow of the ER.  However, we are still on 12 hour shifts and we are still expected to carry more patients than the rotators... about 4 patients at a time.  So we are called "super rotators".... this is all very complicated I know.

Anyhow. My first 4 shifts (all that i've done so far) was a crazy cluster. Its like every patient who comes in here is REALLY REALLY sick.  We are only half thrown the the wolves. We pick up patients and chart and put in our diagnostic orders before

I, as in personally, saw 7 gun shot wounds (GSWs), two of which were life-threatening, bleeding-on the floor, pee-your-pants-cuz-ur-the-doctor-now kinda patients. I had to change my scrub pants twice that night because there was too much blood on my pants to walk around the hospital!! Contrary to popular belief most of the time we leave the bullet in unless its causing problems... I saw 4 septic patients, two of whom I did an internal jugular central line (an IV through the neck which the tube sits in the heart to give certain medications).

I also had a 300lb guy who had headaches, neck pain, and a fever of 103. No nuchal rigidity but luckily I had him walk to the bed from the wheelchair and he was pretty ataxic. So I did my first lumbar puncture. He screamed and legit cried the whole time. It took me about 2 minutes to find the proper spot and I had to get an extra long needle we affectionally call a "harpoon."  But I got it! It was a bloody tap and we ended up diagnosing meningitis.

Another guy came in for a simple headache on and off for the last 2 weeks. He said they were intense pain but lasted only about 5 minutes at a time.  The thing was although his neuro exam was fine, there

was just something off about him. He was having trouble recalling words like "thumb" and seemed to be very distractable, was the text book "inability to concentrate" and so I ordered a CT scan of his head. I had to fight the attending at the time, who was like CT for headaches?? why did you order that? His neuro exam was normal, blah blah blah. Luckily, the scan had already been done by the time he saw I had ordered it.  He had two large masses in his brain, since there was two it was most likely metastasis. And so had to be admitted to try to find the primary cancer. He was close to herniating. Talk about a hell of a first shift!

 They were joking about how I looked like I just got out of high school and I had to tell them he had masses in his brain and likely cancer. It was kinda depressing, yet empowering..... I'm the doctor. And they were looking at me to make the decisions. The attending wasn't there. It was my first solo "bad news" talk.

I also had a patient who came in because he "fell out" which is a phrase they use down here to mean passed out. And hit his face on concrete. He had a really intense nasal dislocation and also had
multiple facial fractures below it. It was crazy. So we had to consult opthomology, plastics, and internal medicine to work up the reason for his passing out. Poor guy. He even let me take a picture because he wanted to see what it looked like. :D

I had another patient who I also thought would be a quick case. Guy came in for back pain, he was a young 30 year old. but the more you talk to him the more symptoms he'd come up with. Problems sleeping and his joints ache and blah blah. Turns out he had osteomyelitis of the spine (bone infection) that was so bad, one of his vertebrae was nothing but pus. Even the surgeons said they couldnt' drain it because then there would be nothing left holding up his spine! So much for simple back pain.

Another one that should have been easy (sensing a theme here?) was cough. Turns out that he coughs while i'm in the room. Didn't sound so bad but there was a bit of blood on the tissue paper. It was hard not to notice. So did just a regular Chest xray.... Then I had to do a CT of chest. Its the biggest cavity of Tuberculosis I have ever seen! Ridiculous! Guess I've officially been exposed to tuberculosis (TB) again!!

I also had to run out to the parking lot twice because I almost delivered a baby there. Too bad the baby was too fast :) Delivered itself. Would have been a great story....

ER Residency: Honeymoon phase

I'm BACK! and kickin'!  I am soooo happy to report that I am no longer in the funk of post-interview, post-graduation.  I needed the break and loved every second that I wasn't studying. And I finally feel like I can breathe again. Although i'm not quite nervous about residency I'm also not dreadding it.

We do orientation this first month while all you suckers get yelled at we are doing simulations, scavenger hunts and being signed off on chest tubes. And as much as I came in skeptical, I like it here. Okay, I maybe LOVE it. You know how you were so excited for college, and super excited and motivated for med school.... well the honeymoon phase of doing what you've finally chosen hits you like a brick.

Maybe its because I don't know any better, but for now: Its BOMB.  Its not perfect, its a pretty dingy old hospital that sounds like there are lots of problems between surgery and er (big surprise).  There are some attending problems but I can forgive it all.

The other ER intern boys... are epically awesome. Its not all about sports like I feared, they instead bonded over making fun of me, which is all in good fun. They make fun of where I'm from and that I'm the "leader" or whatever. Ha! Its like having 8 lewd brothers. I think the key is I join in sometimes on the "that's what she said" jokes and am not easily offended and suddenly its all okay. We have TONS OF FUN. I am friends with them and their wives. I'm a little heartbroken this month will end and we won't all get to hang out as much. Everyone is very smart but more importantly chill, awesome and hysterical. I could go on, but I realize I'm getting rant-y.

So instead a few things for post-graduation facts before I forget.

#1- Medical licenses are a pain in the ass... apply early and immediately.

#2- There is a rumor that you have to get your residency contract read by a lawyer. Some ppl did and some didn't. But you can't actually change it anyway, so just sign it and move on.  (but do read it!)

#3- Consolidate those loans. It takes a few months for that to go through. And although that means you are giving up your grace periods for the loans... if you are aiming for loan forgiveness through public service you gotta make as many payments on them as possible.  I'm doing the whole Pay As You Go during residency. ((edit: if you don't want the PSLF plan then be sure to go ahead an hire a financial planner you trust, we're talking BIG money now kids. We can't make mistakes))

#4- Screw studying before residency. Instead, decorate your new place, go out or plan something for your new interns and make friends. You WON'T have time later.  That social network turned out to be way more important than I thought.

#5- Do something fun.  Get caught up on all your tv shows or movies or hike in Europe, or do whatever! Do something epic. Its your very last months of freedom.  DO NOT WASTE IT.

End Reflections: Things I didn't say

I'm officially done! No more rotations and no more med school. Forever.  It should be more epic feeling that it does right now. Mostly I feel exhausted.  And I don't even really get to relax because I have to finish my thesis, which really puts a damper on finishing. 

I experienced senoritis in high school, some in college, but it was nothing compared to this. NOTHING.  Four board exams and twenty-seven end of chapter exams later..... I honestly experience extreme apathy..... So apathetic actually that I don't even feel like documenting it.

Instead, I will tell you the down and dirty parts of fourth year that I neglected to document because I didn't want it to get around somehow to program directors....

The most stressful part of med school was audition rotations. I know that I wanted ER and all, but I enjoyed those rotations the least-- which I'm still concerned about.  I hated trying to prove myself everyday and feeling like an idiot and constantly being told I was trying too hard but then I was told I wasn't trying hard enough. There was no pleasing them. It wasn't even the academics that were a big deal in auditions-- it was them judging your personality. Everything in chosing a residency is all about your 'fit' with them. Do they want to see you and deal with you for the next several years? They can teach you whatever you need to know, so they want to know how you learn too.
Other people in non-ER also felt this pressure. Several friends of mine going into OB/GYN or even family were judged based on their personality traits being told they were too dark or too bubbly. They had too much apathy.  I was told in a letter of recommendation (not to my face) this phrase:

"Cared for patients with a strong passion. But over-enthusaism and inability to relax made it so we cannot recommend for residency with a strong conscious."

What kinda crock of shit is that? And it wasn't just one audition, another told me I was too apathetic and not caring enough. I had another that told me I was asking too many questions. WTF!  It was all very disheartening and overall I began to wonder if maybe I wasn't fit for ER. My personality was just not good enough, smart enough, fast enough, caring enough, brash enough, or tough enough. I still carry those doubts with me. Its one of the reasons why I was okay with not-matching.

I started realizing that if at the end of the day I hated myself, maybe it wasn't something I should be doing. I also realized that family medicine wasn't something to dump on and that maybe I was kinda good at it. I also thought hey maybe God and the universe is telling me something, so I accepted that I wasn't going to be the ER doctor I thought, and was shocking okay.  Excited even.  And then I got thrown through a loop because I did match.  And now I have to convince myself that this is what I wanted.... and I'm hoping its what I was supposed to do because.... if I'm still miserable in one year, I have every intention of dropping out and trying to get into family med.

There is some point where I can't work this hard for nothing. And hey, if I'm already decent at family med then why not?  I don't wanna work like a dog until i'm 60.  I want to eventually be GOOD at my job. I want to reach a point where I don't have to constantly feel like I don't know what to do. And maybe its a possiblity that I might not be smart enough to do that with ER. And there is no shame in that. I want to have a life outside of medicine where I'm not studying all the time. I want to have a significant life outside of medicine, to the point where I would consider dropping to part time in the future.

I guess I won't know for awhile what to do, and since I'm bound legally to complete the first year of residency I don't really have to decide right now.  I can only hope I'm not the dumbest person in the room and that i'm good at something within ER.

I also feel somewhat uncomfortable since I'm the only girl in my incoming class. And i still feel like ER is a boys club and I will be left out with any social events. Especially since sports is really not my thing and in ER especially, sports is everyone's thing. Maybe I can be friends with other residents in other specialties.


Its also worth mentioning that several of my audition rotations were 'wasted' because i decided after my rotation there that there was no way in HELL i would ever put that site on my list. That was 3 of the 4 rotations i did. And in that way I also wished I had spent more time thinking and looking into where I did my auditions. At least I know now what size hospital I wanted to train at.... I spend a lot of time thinking about if I had done my list differently would I have got a different spot or not matched or what.... Its kinda unfair we never find out where the place ranked us or what other places thought of us.

whelp... graduation is soon and I gotta get going on this stupid thesis.

In the meantime, I plan to continue this blog into residency although the consistency of the posts may or may not be reasonable.  But i will do my best.

Until July....

Elective: Prevention, Nutrition, Anesthetics, Wt loss

So this guy has a different look at medicine.

He is a D.O. And he believes that instead of waiting until disease gets to the point of train wreck, we should treat early to prevent. Basically, we wait until a disaster hits and try to fix it and dont understand why patients still feels crappy.

So he uses the idea of balance and whole body wellness to look at the big picture and then the bad stuff tends to get better on its own. So he looks at nutrition using both blood and urine, as well as toxins like mecury and lead, he also does several specific labs for absorption, tests everyone for hormone levels (not just sex hormones, but thyroid, insulin, and neurotransmitters).  He uses these labs and supplements and diet, exercise to balance those who come into his office.

Its been quite an experience, because I've seen him get his patients off their blood pressure meds, their insulin, and lose weight.  I've seen them stop smoking and they ACTUALLY FOLLOW HIS DIRECTIONS.  And i think the key is he charges cash only and waits until they come to him.  So his patients are those who actually want help.

Its been inspiring to see. And having all his patients leave feeling a little better or looking a little better. I'm surprised at how looking better has a huge impact on mental and physical health. Lots of people who other doctors would call coukey or crazy into alternatives, are really looking for science to help with true health.  Many of them are really sick and have been screwed by regular medicine. Others have always been healthy or alternative and want to stay that way.  Its a good reminder.

My time here has been fulfilling. Being in a healthy atmosphere helps me stay health conscious. It helps the staff and even to some extent the patients. Losing weight, everyone having protein shakes and going to the gym, and sharing good tasting but healthy recipes actually works on my health. I've gone to the gym 5x week and felt pretty good about the things i eat and whatnot. Its good to have that reminder and that motivation.

I'm glad to end my med school career with this good reminder to keep my mind open and don't blow them off. Remembering that patient education is still really important, the diagnosis isn't always the finish line, and prevention is really where it needs to be.

I'd love to come back years from now and consider opening up my own clinic like this and help those around me get healthier.

The Match Post!

So it's official. I matched. Despite all signs to the contrary (the lack of communication by program directors, the very few interviews), I got an Emergency Medicine Residency.  Half of me wonders if that's because of how I ranked my list.  

When the program director called me, he spent time phrasing things like "We hope its a happy day" and "we know we're not everyone's first choice" which made me scared more than anything. I had second thoughts like, wow, was this really a not-so-good program afterall?

Being that I want to continue this blog as residency begins, I will not be revealing where I matched to. To keep HIPPA rules private and all of that. 

____THE UNMATCHED____
I was also really shocked, because I had prepared to not match, had even written a second personal statement, had done everything I needed to scramble (or participate in SOAP they call it).  I had friends who scrambled and it was kinda a shit-show. I had no idea it was that unorganized.  Plenty of good candidates didn't get spots, got phone calls from directors in the scramble promising spots or saying things like "we really like you" and then no offers during the first rounds of SOAP.  It was very disheartening. Only half of my friends who did not match, got a scramble spot.  And those transitional years that were everyone's backup--- filled up fast. And family wasn't as easy to get as everyone said it was.

6 of the 13 friends I know who didn't match were Peds!!  This baffles my mind. Peds is supposed to be easy to get into.  I guess in the end it made more sense tho because those specialties who were likely to not match: surgery, ortho, etc -- had anticipated that and actually interviewed for transitional years. The rest of the friends who didn't match were things like: OB/GYN, EM, gen surg, and even one family. 

That said, I was still really gung-ho family because I spent the last two months convincing myself that family was what I really wanted. Especially after that Rural Family Med/Free Clinic rotation.  I was really all ready.  So now I'm faced with some disappointment.

Despite the fact that I spoke to several family docs, who despite liking their jobs also hate them-- every piece of paperwork, every argument with insurance, and every patient who does nothing to help themselves with health. 

In the end, I dunno if my planning mattered or not because the Almighty Match has spoken.  And i am legally bound to go to my residency spot for one year even if I didn't want to.  Which means for you med students out there.... rank only the programs you actually COULD go to. And during the whole process you keep say "i just want to go anywhere as long as they take me" and that is a big fat lie. There are obviously places you dont want to go. So be real and honest with yourself.

_____AN ASIDE FOR THE MATCHED____
Getting yoru temporary medical license is something you have to apply for almost immediately after you get matched because it takes so dang long (12 weeks or more).  Every state is different and requires different paperwork. Its a crazy pain in the butt and everything has to be notarized including your copies of birth certificates and whatnot. So make sure you get that paperwork in on time, because you can't start your new job without it!

On top of all that stuff, you also have to get your 98th TB test (Come on people!! Why are you torturing me?) and another health check, another drug test, a really intense FBI background check where they take your mom into a dark room (not really) but it seems like that. They call everyone you've ever known or passed on the street.

____BEYOND THAT____

In the meantime, I have soooo much to do. Getting things ready for graduation has completely trumped the celebration I might have held for the fact that my last med school rotation is April 12th!?!?! WOOOO!! I had no idea graudating was this much paperwork, invites, and preparation.

A word of advice for all med students who are in the process of graduating.  It is very exciting and it seems like all you want to do is go find a new place to live (which you should do).  But also, do 1 thing that has absolutely nothing to do with school.   Take a VACATION. Because from what i hear you don't get any vacations in residency. And it is harder than med school ever was because you're actually responsible for your patients.

Frankly, I'm secretly terrified I'm going to be a horrible resident and an even worse doctor because i don't really know anything...... I think my board scores prove that.  ((Does that mean I can get off the hook?)) But I am taking a big vacation ( a whole week and a half) and I'm also gunna get a puppy. I'm pretty sure.

Guatemala: summary stuffs!

So this is the honest truth. Preparing for this trip was a nightmare. It is supposed to be a rotation. But the faculty sit back and want the students to lead, which is fine and good, but they gave the student leaders no guidance or instruction as to what needs to be done until its already due. And a peer leader, especially of some 30 odd 4th year medical students who are burnt out and just want to chat to their friends, is not going to make them do their work. Those peer leaders have no authority because there are no consequences for not listening. So it was frustrating just sitting around for hours trying to figure out what drug assortment needed to be in what trunk with what supplies in what order. Not to mention figuring out how each drug needed to be sorted and counted. It was kinda a nightmare of communication. And the faculty sorta treated it like a vacation. And who could blame them. 

Guatemala was GORGEOUS! Its just like the pictures. Warm, but not tropical and unusual plants, flower, weather, animals, and culture everywhere. There is a difference between the Mayans and Guatemalans, not just in language but also in stature. Our schedule was pretty decent. We were gone 2.5 weeks and had 8 days of clinic.  Each day of clinic was at a different village and usually lasted from 9am until dusk. We traveled on colorfully painted school buses (called chicken buses) for several hours to get to the villages on unpaved roads in moderately poor condition. Some of the villages are poorer than others, and I couldn't help but notice that we didn't really seem to stop at the poorest or the Mayan villages. I guess its a political thing being the Guatemalan govt decides where we go. But we did have very LONG lines of people waiting when we got there and always had to turn more away when we left. I do have to say that I thought 12 hour clinic days were exhausting but add to that treating people in families as fast (and as efficiently) as possible and speaking only in broken Spanish with very limited resources often in school kid chairs or church pews and exhausted doesn't even cover it. I spent most of the rides home feeling like a puddle. I was so glad we got a 3 days weekend between the clinic days or I might have forgotten my own name. 

But our days 'off' weren't really off. We spent them doing excursions-- I don't regret them, but I sure didn't get much sleep. So we hiked the Volcano Pacaya which is an active volcano pictured above. Although it looks like clouds are always perfectly positioned above that mountain it was legit steam. The freakin thing erupted while we were there, which was mostly uneventful but we did get to roast marshmallows over the lava- which was EPIC. Best marshmallow I've ever had. But it was a very strenuous climb.  We also spent some time on a black sand beach, boy was that sand hot. The water had the strongest rip tide and under toe that I've ever experienced, but I got to spend a day in a hammock reading a novel.... I have a hard life :)

I also go to zip line over a coffee plantation and then tour the plantation afterward. Did you know coffee comes from a red fruit that resembles a large grape and that 1 lb of beans = 1 plant? And that the lighter the brew of coffee the more caffeine? I guess the brewing process takes out caffeine rather than allowing more through. Oh the things I never knew! I loved the coffee there. Coffee in Guatemala doesn't have a bitter aftertaste. it was awesome. 

We also go to go see Mayan Ruins from the post-classic age, called Mixco Viejo with multiple temples. We had a Mayan Xamen accompany us and participated in a Mayan Ritual that blessed humanity. It was very... informative. I have to say that the Mayan people have earned my respect in many ways. I mean they were doing brain surgery while my people still believed the earth was flat. Granted the Mayans also believed that if a man cut his penis and bled into a fire a substantial amount he could breathe in the smoke and see the future, also maybe would pass out and be sterile for life but hey, why not? They also believed that jade was from heaven and shell was from the underworld and in order to wear jade you had to wear shell somewhere on your body. I never knew that there were different shades of jade and not all were green. I guess there is also black and lilac jade that are exclusive to guatemala. Google it, its really cool.

Other time off or spare moments we spent wandering Antigua, trying to look at the market and buying things. It was fun because their currency is called the Quetzal and you are expected to bargain... in Spanish. It was kinda fun to get good at it. Also to realize that 900 Quetzals in about $100 US Dollars.  Everything they sold was very bright colored with pretty cool designs. 

Overall, I loved the coffee, patients, and getting SO MUCH BETTER at Spanish the most. I got the most annoyed with being unable to flush toilet paper, the cold showers, and the excessive drinking that most of my fellow med students participated in during the trip. But it was so worth it.   And to get a tiny taste of this trip, here are a few pictures...

My Rank List

Rank lists were due today! So... about rank lists and matches. As I've already explained, the Match is a computer algorithm that will assign every medical student int he country their residency program based on a list we call the 'rank list' -- a numbered list of the student's preferences for residency in order. You can only list the programs that have interviewed you----  and the 'rank list' submitted by the programs of the students they have interviewed listed in numbered order.  The computer uses the lists to 'match' the student to the program. 

Since this is 2013, the D.O. match and the M.D. match are seperate still--- this is going to merge into one big match in 2015 (those LUCKY DUCKS!). Since we don't have that we have to chose between the matches because the D.O. match happens in feb and the M.D. match happens in march.

 Long complicated story short... after much deliberation I chose to drop out of the D.O. match. Ultimately, I applied to 60 ER programs got a total of 10 interviews.  5 DO and 5 MD.  (ironic no?)   When I looked at my list, my #1 & #2 are MD and after 4 years of med school i couldn't give up on a chance of getting them. They were just so much more my style than any other programs I saw, I made the decision to ditch the DO. Maybe this was a good decision maybe it wasn't. But I couldn't help but notice that in ER at least, the quality of the programs was just night and day. DO programs were just not as organized or polished and seemed to have less trauma. Obviously there are some exceptions. Anyhow, its what I did. For those wondering how I chose this list, its all about 'fit' and honestly I thought where would i be happiest? Where did the people seem like I would be friends with easiest? And maybe some about location, but mostly just where I fit best. So here is My Rank list....

1. University of Mississippi in Jackson, MS
2. John Peter Smith in Fort Worth, Tx
3. University of Nebraska in Omaha, NE
4. St. Francis in Peoria, IL
5. St. Vincent in Toledo, OH
6. Lehigh Valley in Allentown, PA  (this is dual program)

So on March 11th I will get an email that says either::  'matched'  or 'unmatched'   at this time if i'm matched I wait until March 15th when I get another email that says what program I matched to.

If i am unmatched, which is unfortuntely likely, since I really needed to rank 10 places to be assured of a match (ER is very competitive this year), I must enter the scramble (also called SOAP).  This involves me logging in to access the list of programs with spots after the match.  I then re apply using ERAS to 30 programs.  These programs I chose from will be in a variety of specialties and most likely will not be ER spots. Usually the unfilled spots is one of four: family med, internal med, psychiatry, and transitional year.  I chose not to enter transitional year because of funding cuts to Medicare (they pay residents salaries) they make it less likely for programs to want to pick up residents who already have been paid 1 year -- this will increase the chance that the hospital or program will have to pay the last year of the residents salary.  Anyhow, this was a really hard and crappy decision to make.  This boils down to meaning I may not end up being an ER doc like I wanted, but I am making this move so I can have some kind of paying job next year without having to go through this HELL another year.

So here's to my uncertain future and to March 11th, when I find out what kind of doctor i will end up being.....

(Edit: Before I forget I know 10 people personally who did not match in the DO match this year who ranked more than 8 places. Not looking good! Their specialities were: ER, Ob/GYN, Surgery. The NRMP reports that 10,000 med students won't match this year in the MD match. I'm getting freakin nervous!)

Guatemala!!!

Yeah. This is happening in Feb. I'm leaving tomorrow at like 3am.  So more later.

Underserved: Free Clinic & Homeless shelter

So this is a required rotation and honestly, I signed up for the site I did was because I wanted to be close to home. I also wanted to blow it off because I was so burnt out of working in places where I have to try to prove to someone every second of every moment that I belong there.... I just wanted to something chill. So I picked somethin close to home.  And my school strong armed me into this place 45 minutes away from my parents.  Its a free clinic right next to the homeless shelter, where I slept during the week--- partially.

And it was so much better than I ever could have asked! This rotation is stressful because well, any rotation during January is because that is when all medical students have our Rank List is due. (more on that in a different post).  Anyway, suffice it to say I have to sum up all the choices I have for residency.

But this place functions only on volunteers. Which means that we only had docs, what 4 days I was there. The rest of the time we had other students and the one nurse practitioner who ran the place and signed our scripts if needed.  So it was ALL me. Nobody checked behind me. I was the doctor.

It was intimidating but it also was the single best learning experience I've ever had.  It forced me to go remember what I learned and remember mistakes on the job. And the clinic was special. We didn't deal with insurance. So it means that I now know almost every medication on the $4 list by heart and where to get what medication for cheaper. I also now know the dosages for most of the antibiotics as well.  For example did you know, Albuterol inhalers without insurance costs $45.

Beyond no insurance, we also don't have nurses. So we did our own procedures. Preg tests, Urine Analysis, Blood Sugar, Vaccinations, and all the paper work that goes with it all. Its actually super helpful to know.

My favorite part was working with so many students. Nurse practitioners and PAs and med students. And we could all sorta be each other's brain trust and bounce ideas off each other and it was the kind of environment I wanted to work in!

This whole thing ended up being pretty cool, because my patients would call in and ask me questions or specially request me. I had refills and it made me feel very official.

So i decided that if i don't get into ER this year.... I will be applying for family med.  And maybe I won't be so unhappy with that....